Is there adequate information on operation notes? The application of the Royal College of Surgeons of England guidelines.
The General Medical Council (GMC) requires that every doctor should, '... keep clear, accurate and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to the patients and any drugs or other treatment prescribed', as a cornerstone of good medical practice (GMC 1998).
Errors in documentation are known to occur in all medical specialties with a possible range of adverse clinical and medico-legal consequences (Brennan et al 1991, Cradock et al 2001). Comprehensive and contemporaneous medical notes afford the greatest clarity in patient management and all medical professional should strive to achieve this (Joint Commission Resources 2006).
A key finding of the 2009 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report, analysing the care of patients that died within four days of hospital admission, is that poor documentation remains commonplace in all aspects of the management of surgical patients and remains of concern (NCEPOD 2009). This is particularly relevant to the operative record. Immediate post-operative, pre-discharge and long-term patient care may all be influenced by the quality of the record. With the present emphasis upon clinical governance, the future educational value of individual cases, or collective cases for audit, will rest upon the quality of the data recorded. Thus the standard of the operation note is crucial for enhancing patient care both individually and globally--the aim of all health care professionals.
In today's litigious climate, it is impossible to ignore the medico-legal implications of poor record keeping (Williamson 2001). Part of the Royal College of Surgeons of England's accreditation process, a surgical audit programme, is deemed essential in both monitoring and maintaining an optimal level of patient care (RCSEng 1995). As an adjunct to this process, the college has produced guidelines to systematically standardise clinicians to a desired level of record keeping (RCSEng 1994). Without reference to these recommendations, it has been suggested that the standard of operation notes needs to improve (NCEPOD 2009). This study audited the effect of utilising the RCSEng guidelines on the quality of operative notation in a plastic surgery department.
Concerns were raised at departmental meeting following anecdotal reports of poor documentation of the operative record. As a consequence of these concerns, and with the express approval of both the department of plastic surgery and the surgical directorate, a retrospective survey was performed tracing all surgical procedures carried out by the department of plastic surgery over six weeks. The medical notes containing the operative record were obtained.
[FIGURE 1 OMITTED]
Every operation note was assessed independently by each author for the inclusion of the criteria stipulated by the RCSEng (RCSEng 1994), as well as the grade of surgeon and date of surgery. A proforma was used to make this process uniform (Figure 2), and thus for every operation note there were two completed proformas. As stipulated by our hospital ethics committee, the names of the surgeon and the patient were not incorporated in any of the data collection or proformas.
The results of this survey were discussed at a departmental meeting. It was evident that some of the criteria were not wholly applicable to plastic surgery and that there were some deficiencies in the recording of data (vide infra). However, the results of the initial survey were sufficient to determine that an intervention was required to improve the quality of the operative note data set. All of the senior members of the department agreed with the need to improve documentation and details of the methodology regarding the subsequent section of the audit were disseminated. This included ten key points that were considered necessary documentation for an operative procedure that formed the basis of an aide-memoire (Figure 2).
[FIGURE 2 OMITTED]
We initially conducted a small pilot study with copies of the proforma printed out and stapled to the routine operative sheet used. However, in order to ease logistics, we purchased a custom ink stamp, enabling the proforma to be stamped in the bottom right hand corner of the operation sheet. This afforded the proforma to be included in a quick and straight-forward manner, without the need for further paper sheet in the medical notes.
Importantly, a second column necessitated a tick if, in the opinion of the surgeon, the category was not relevant to the procedure undertaken. The nature of the intervention was widely publicised to all surgeons within the unit after the initial survey. All operative notes were stamped in advance of distribution to theatres. In order to complete the audit, all operative notes were assessed for completeness after the two-month period of the intervention. Statistical analysis was carried out using statistical package SPSS for Windows version 11.0. Pearson's Chi-Square Test or Fisher's Exact Test was used dependent on the number of group responses. The significance level was set at p>0.05.
[FIGURE 3 OMITTED]
For the initial survey, 137 separate patient operative notes were assessed and later compared with 151 sets of notes with completed aide memoires. Figure 3 and table I compares the groups.
There were 89 sets of operative notes in the later time period for which the aide memoire was not completed. Inspection of these revealed that despite the aide memoire not being ticked, there were still changes in the documentation of the responsible surgeon and tissue added, altered or removed (Table I). Failure to complete the aide memoire was most frequently attributed to consultants (42; 47%) registrars (36; 41%) and then senior house officers (11; 12%).
A high quality of operative notes is something that has been advocated by both the GMC (GMC 1998) and the RCSEng (RCSEng 2002). In reality the standard is often poor which has several serious implications: for patient care (NCEPOD 1994), medico-legal/risk management (Reed & Phillips 1994) and audit.
Previous studies have shown that operative notes are often lacking basic details and that the use of an aide-memoire can facilitate improvement (Bateman et al 1999, Din et al 2001). In comparison, this study utilised the RCSEng guidelines (RCSEng 1994) for an audit of operative notes and quantifies their relevance when applied to a litigation-prone speciality, plastic surgery (Gorney 1999).
The intervention resulted in a significant improvement in the documentation of both operating surgeon and responsible surgeon. This has potential clear benefits for continuity of care and audit. The 10% increase in the documentation of diagnosis was significant; however, in 19.2% of cases the operative surgeon indicated that the diagnosis was deemed not to be applicable. In these cases, the operation was most frequently for both the diagnosis and treatment of a skin lesion. A significant decrease was seen in the recording of tissue altered/added or removed (85.4% to 43.1%). This may be explained by over half (56.9%) of the operating surgeons indicating that this criterion was not applicable to the plastic surgery procedure carried out. This is clearly at odds with the assessment of operative notes in the initial survey when 85.4% of cases were felt to have a written description of 'tissue altered/added or removed'. Strictly, there are unlikely to be any plastic surgery operations where tissue is not altered in some manner but the operative surgeon may have focused on the 'added or removed' part of the criteria. This suggests that in future studies, it would be prudent to explain the exact meaning of each of the criteria to all parties involved in the audit.
Prosthetic materials, although essential for certain plastic surgery procedures such as tissue expansion or metacarpal joint replacements and in other surgical specialties such as trauma and orthopaedics, do not play a major role in the caseload of a typical plastic surgery department. This is confirmed by prosthetic materials not being appreciably recorded in notes and 92.7% of surgeons in the second survey indicating that the criteria was not valid for the stated operation. Similarly, a description of difficulties encountered was not deemed to be applicable to the majority of procedures undertaken in the second time period (87.4%), but it was nevertheless encouraging that the aide memoire resulted in a small but significant improvement in documentation (5.1% versus 12.6%). The detailing of the nature of the suture was excellent before the intervention and as such, it was not surprising that there was minimal improvement. It failed to reach 100% due to scenarios such as the occasional need for a change of dressings on major burns in theatre. Finally, a welcome benefit of the aide memoire was the significant improvement in the expression of clear post-operative advice from 78.1% to 100%.
Overall, the results show that an aidememoire does improve documentation and we aim to continue to improve the percentage of cases in which it is used. In the future, we aim to improve and refine the use of an aide-memoire by incorporating them in to the care pathways, thus enabling them to be procedure specific. This would be of particular benefit in reconstructive plastic surgery and could, of course, be copied in other surgical specialties such as orthopaedics.
This audit demonstrated that the RCSEng operation note guidelines cannot be universally applied and this should be taken into account for future audits of notes in surgical specialities. Of particular concern is that non-clinical audit staff using RCSEng guidelines might erroneously interpret particular operative notes as a failure to document categories such as diagnosis, or have different concepts from the surgeon of criteria such as the alteration of tissues.
This study highlights that the RCSEng guidelines are not universally applicable to plastic surgery, although their use in the form of an aide-memoire did improve the quality of surgical record keeping. Thus the need exists for more specific guidelines, relating to different surgical specialties and sub-specialties, and the failure to do so may lead to incorrect interpretation and clinical governance implications. We would advise any department to clarify these issues prior to conducting a similar audit.
As suggested previously (Din et al 2001), these results provide further evidence that the use of an aide-memoire improves the standard of surgical record keeping. Moreover, even when the aide memoire is not completed, there was a suggestion that its presence on the operative note page encouraged a trend to improvement in the documentation of most criteria. However, it remains to be proven whether an improvement in the quality of operation data has the desired secondary effects of improved patient care, audit and better defence against litigation.
This study demonstrates that the simple addition of an aide-memoire to the operation sheet affords significantly superior documentation of the surgical procedure. The widespread introduction of such a technique should be discussed at length with both the clinicians in each surgical specialty and the clinical governance department to ensure that no inappropriate interpretation occurs.
Bateman ND, AS Carney, Gibbin KP 1999 An audit of the quality of operation notes in an otolaryngology unit Journal of Royal College of Surgeons of Edinburgh 44 (2) 94-5
Brennan TA, Leape LL Laird NM et al 1991 Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I New England Journal of Medicine 324 (6) 370-6
Cradock J, Young AS Sullivan G 2001 The accuracy of medical record documentation in schizophrenia Journal of Behavioural Health Services & Research 28 (4) 456-65
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General Medical Council 1998 Good Medical Practice London, GMC
Gorney M 1999 The wheel of misfortune. Genesis of malpractice claims Clinics in Plastic Surgery 26 (1) 15-9 v
Joint Commission Resources 2006 Risk management: Assessing risk in medical documentation: Comprehensive medical records can be your greatest protection Joint Commission Perspectives on Patient Safety 6 (2) 3-8
National Confidential Enquiry into Patient Outcome and Death 1994 The Report of the National Confidential Enquiry into Perioperative Deaths 1992/3 London, NCEPOD
National Confidential Enquiry into Patient Outcome and Death 2009 Caring to the End? A review of the care of patients who died in hospital within four days of admission London, NCEPOD
Royal College of Surgeons of England 1994 Guidelines for Clinicians on Medical Records & Notes London, RCSEng
Royal College of Surgeons of England 1995 Guidelines to Clinical Audit in Surgical Practice London, RCSEng
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Reed MW, Phillips WS 1994 Operating theatre lists-accidents waiting to happen? Annals of Royal College of Surgeons of England 76 (6) Suppl 279-80
Williamson J 2001 Good Record Keeping. In Union MD Medical Defence Union (ed), London
Correspondence address: Mr Benedict A Rogers, Lower Limb Arthroplasty Fellow, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario, Canada, M5G1X5.
Benedict A Rogers
MA MSc MRCGP FRCS(orth)
Lower Limb Arthroplasty Fellow, Mount Sinai Hospital, Toronto, Ontario, Canada
Specialist Registrar, Plastic & Reconstructive Surgery, Oxford
No competing interests declared
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Table 1. A comparative table of the completeness of operative note information before (primary survey) and with (secondary survey) the use of an aide memoire of desired criteria. Significance at p > 0.05 level compared to primary survey indicated by *. Initial Secondary Survey (n=240) Survey (n=137) Criteria to be Aide memoire used (n=151) documented Criteria Not ticked applicable ticked Operating surgeon 130 (94.9%) 151 (100%) * 0 Responsible surgeon 54 (39.4%) 151 (100%) * 0 Procedure performed 136 (99.3%) 151 (100%) 0 Diagnosis 97 (70.8%) 122 (80.8%) * 29 (19.2%) Findings described 104 (75.9%) 141 (93.4%) * 10 (6.6%) Tissues altered/added/ removed 117 (85.4%) 65 (43.1%) * 86 (56.9%) Noted use of prosthetic material 7 (5.1%) 11 (7.3%) 140 (92.7%) Suture details 128 (93.4%) 143 (94.7%) 8 (5.3%) Described difficulties encountered 7 (5.1%) 19 (12.6%) * 132 (87.4%) Immediate post-operative instructions 107 (78.1%) 151 (100%) * 0 Secondary Survey (n=240) Criteria to be Aide memoire documented not used (n=89) Criteria documented in written notes Operating surgeon 87 (97.8%) Responsible surgeon 57 (64.0%) * Procedure performed 89 (100.0%) Diagnosis 64 (71.9%) Findings described 71 (79.8%) Tissues altered/added/ removed 49 (55.1%) * Noted use of prosthetic material 6 (6.7%) Suture details 83 (93.3%) Described difficulties encountered 6 (6.7%) Immediate post-operative instructions 77 (86.5%)
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|Title Annotation:||CLINICAL FEATURE|
|Author:||Rogers, Benedict A.; Pleat, Jonathan|
|Publication:||Journal of Perioperative Practice|
|Date:||Sep 1, 2010|
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